Evolution of Risk for Neurologic Deficit After Descending and Thoracoabdominal Aortic Repair

Bloody cerebrospinal fluid during replacement of descending thoracic aorta -A case report-

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct to thoracoabdominal aortic surgery which may reduce the incidence of preoperative paraplegia by improving spinal cord perfusion. However, this procedure infrequently causes complications. Bloody or bloody-tinged CSF may be associated with intracranial or spinal hematoma. We present herein a case of bloody CSF during the replacement of the descending thoracic aorta.

Effect of chronic dissection on early and late outcomes after descending thoracic and thoracoabdominal aneurysm repair

OBJECTIVE

Although chronic aortic dissection (CD) has traditionally been considered a predictor of perioperative morbidity and mortality after descending thoracic/thoracoabdominal aneurysm repair (thoracoabdominal aortic aneurysm [TAA]), recent reports have rejected this assertion. Still, few contemporary studies document late outcomes after TAA for CD, which is the goal of this study.

METHODS

From August 1987 to December 2005, 480 patients underwent TAA; 73 (15%) CD and 407 (85%) degenerative aneurysms (DA). Operative management consisted of a clamp-and-sew technique with adjuncts in 53 (78%) CD and 355 (93%) DA patients (P < .001). Epidural cooling was used to prevent spinal cord injury (SCI) in 51 (70%) CD and 214 (53%) DA patients (P = .007). Study end points included perioperative SCI/mortality, freedom from reintervention, and long-term survival.

RESULTS

CD patients were younger (mean age 64.5 years CD vs 72.5 years DA, P < .001) and more frequently had a family history of aneurysmal disease (23% CD vs 6% DA, P < .001). Forty-three (59%) CD patients had elective TAA (vs 322 (79%) DA, P = .001). Eleven (15%) CD patients had Marfan's syndrome (vs 0% DA, P < .001), and 17 (23%) CD patients had a prior arch or ascending aortic repair (vs 16 [4%] DA, P < .001). CD patients were more likely to have Crawford type I & II thoracoabdominal aneurysms (44 [60%] vs 120 [29%] DA, P < .001), while only two (3%) CD patients had type IV aneurysms (vs 99 [24%] DA). There was no difference in perioperative mortality between the two groups (11% CD vs 8.6% DA, P = .52), nor was there a difference in flaccid paralysis, which occurred in five (7%) CD and 22 (5%) DA patients (P = .92). At 5 years, 70% of CD patients were free from reintervention versus 74% of DA (P = .36). The actuarial survival was 53% and 32% at 5 and 10 years for CD versus 47% and 17% for DA (P = .07).

CONCLUSIONS

Despite increased operative complexity, CD does not appear to increase perioperative SCI or mortality after TAA when compared with DA. Long-term freedom from aneurysm-related reintervention is similar for both groups as is survival, despite patients with CD being of younger age at presentation.

Female patients undergoing TEVAR may have an increased risk of postoperative spinal cord ischemia

BACKGROUND

There is a paucity of literature regarding thoracic endovascular aneurysm repair (TEVAR) in women. We report our institutional experience with TEVAR.

METHODS

Retrospective chart review was performed from 2004 to 2008. TEVAR was performed in 59 patients; 29 (49%) were female.

RESULTS

Mean age was 73.5 years. Mean thoracic aortic aneurysm (TAA) diameter was larger for women (5.9 cm vs 4.7 cm). A trend toward an increase in paraplegia was noted in women, 10.3% vs 4.8%. This may be related to increase in length of aortic coverage in women, 18.2 cm vs 15.2 cm (P < .05).

CONCLUSION

TEVAR in women is safe and effective. The length of aortic coverage is greater in women, which may be related to larger aneurysms and more diffuse disease. This may be associated with a concerning increase in postoperative paraplegia. Women undergoing TEVAR should be considered for prophylactic maneuvers to prevent spinal cord ischemia (SCI), including minimizing length of coverage.

Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity

OBJECTIVE

Paraplegia after thoracoabdominal aneurysm (TAA) repair has been associated with poor survival. Little information exists concerning the spectrum of severity that characterizes spinal cord ischemic (SCI) complications. This study stratified SCI by deficit severity to determine its impact on late survival and functional outcomes.

METHODS

A review of our prospectively maintained thoracic aortic database was performed from May 1987 through December 2005 to identify patients who experienced SCI of any extent after TAA repair. During this period, 576 patients underwent descending thoracic aortic repair (93 open, 105 endovascular [TEVAR]) or open TAA repair (279 extent I to III; 99 extent IV). To stratify severity of SCI, we created a spinal cord ischemia deficit (SCID) scale, which is defined as: I, flaccid paralysis; II, average neurologic muscle grade indicating <50% function; and III, average neurologic muscle grade indicating >50% function. Long-term outcomes were evaluated in relation to these groups by actuarial methods.

RESULTS

During the study period, 64 (11.1%) patients developed SCI of any severity (7 of 105 [6.6%] TEVAR, 57 of 471 [12%] open). These were stratified by SCID level: I, 24 (37.5%); II, 31 (48.4%); and III, 9 (14.1%). SCI was immediate in 33 (54.1%) and delayed in 28 (45.9%). Most SCI (6 of 7) associated with TEVAR was delayed. The 30-day mortality was significantly higher in the SCI group than the overall patient cohort (15 of 64 [23.4%] vs 41 of 512 [8%], P < .001) and varied by SCID level: I, 11 of 24 (45.8%); II, 4 of 31 (12.9%); and III, 0 of 9 (0%; P = .001). The 5-year actuarial survival for all SCI was lower than for non-SCI patients (25% +/- 6% vs 51% +/- 3%, P < .001) and varied linearly with SCID level but was similar between SCID II/III and the non-SCI patients (41% +/- 10% vs 51% +/- 3%, P = .281). No SCID I patients were alive at 5 years. No patients with SCID I recovered the ability to walk, but eight of 11 (73%) with SCID II and the nine (100%) with SCID III could ambulate with or without assistance at last follow-up.

CONCLUSION

Survival and functional outcomes correlate with SCI severity. Patients with SCID I have a poor long-term outlook. Survival of SCID II/III patients is similar to non-SCI patients; most recover the ability to ambulate.

Early Results after Staged Hybrid Repair of Thoracoabdominal Aortic Aneurysms

BACKGROUND

The morbidity and mortality rates associated with open thoracoabdominal aortic aneurysm (TAAA) repair are substantial. This study was designed to review our early experience with the hybrid endovascular and, or open approach for TAAA repair.

STUDY DESIGN

Patients undergoing elective hybrid repair of their TAAAs were retrospectively reviewed.

RESULTS

Seventeen patients (mean age 69+/-15 years, male, 76%) underwent visceral and renal revascularization as the first stage of their hybrid repair. The Crawford extent included: II, 2; III, 8; and IV, 7. Perioperative mortality and complication rates after the first stage were 24% and 25%, respectively; the mean intensive care unit stay and total length of stay were 7+/-12 days (range 1 to 45 days) and 22+/-33 days (range 3 to 100 days), respectively. The endovascular aneurysm repair or second stage procedure was performed in 12 of 13 (92%) of the surviving patients, with a mean of 27+/-27 days (range 6 to 99 days) between the procedures. Two patients experienced intraoperative complications during the second stage, but there were no deaths or additional postoperative complications. Patients did not require the intensive care unit, and the overall mean length of stay after the second stage was 2+/-2 days (range 1 to 5 days). The mean postoperative followup among the 11 patients completing both stages was 8+/-12 months (range 1 to 15 months). The primary patency rate for the visceral and renal bypasses was 96% (54 of 56).

CONCLUSIONS

The hybrid approach for patients with TAAAs may reduce complications in the average, low-risk patient and may extend the indications for repair to patients considered higher risk based on age, comorbidities, or anatomic considerations.

Role of Somatosensory Evoked Potentials in Predicting Outcome During Thoracoabdominal Aortic Repair

BACKGROUND

Clinical utility of somatosensory evoked potentials (SSEP) in descending thoracic and thoracoabdominal aortic repair is debated. We reviewed our practical experience with SSEP in descending thoracic and thoracoabdominal aortic repairs.

METHODS

Between January 2000 and April 2005, we used SSEP monitoring in 444 patients (270 thoracoabdominal aorta and 174 descending thoracic aorta). Median age was 68 years; 36% were female. Only changes of spinal origin were analyzed. Changes were classified as (1) no change, (2) transient changes that returned to baseline by the end of the procedure, or (3) persistent changes that did not return to baseline by the end of the procedure.

RESULTS

Somatosensory evoked potential changes occurred in 87 (19.6%) patients; 22 (25%) of these did not return to baseline. Immediate neurologic deficit occurred in 8 of 444 patients (1.8%); five deficits (5 of 87; 5.8%) occurred in patients with SSEP changes, compared with three deficits (3 of 357; 0.8%) in patients without changes. Odds ratio for this comparison was 7.2 (p < 0.002). Somatosensory evoked potential was a poor screening tool for neurologic deficit, with a sensitivity of 62.5% and specificity 81.2%. Negative predictive value was 99.2%, indicating a very low event probability in the absence of SSEP changes. Delayed neurologic deficit occurred in 3.2% and was not related to SSEP changes. Somatosensory evoked potential changes were also associated with increased 30-day mortality and low glomerular filtration rate.

CONCLUSIONS

Intraoperative SSEP monitoring was reliable in ruling out spinal injury in descending thoracic and thoracoabdominal aortic repair, but had a low sensitivity. It did not predict delayed neurologic deficit. Spinal SSEP change was an independent predictor of mortality and correlated with low preoperative glomerular filtration rate.

Hybrid Thoracoabdominal Aneurysm Repair With Simultaneous Antegrade Visceral Revascularization and Supra-Aortic Debranching from the Ascending Aorta

PURPOSE

To describe a hybrid technique involving combined antegrade revascularization of both supra-aortic and visceral arteries and complete exclusion of a dissecting thoracoabdominal aortic aneurysm (TAAA).

TECHNIQUE

A 46-year-old man had a dissecting TAAA involving the left subclavian artery (LSA) and the descending thoracic and abdominal aorta down to the left common iliac artery. The ascending aorta was the only feasible source of inflow to the cerebral and visceral vessels. Via a median thoracolaparotomy, the supra-aortic and visceral arteries were dissected, and an octopus graft was implanted using 3 bifurcated Dacron grafts. An 18-x9-mm bifurcated Dacron graft was anastomosed in an end-to-side fashion to the ascending aorta, the brachiocephalic trunk, and the left common carotid artery. A 16-x8-mm bifurcated Dacron graft was sutured end-to-side to the celiac artery and superior mesenteric artery. A third 12-x7-mm bifurcated graft was sutured to both renal arteries. In a second step, 3 tapered custom-made thoracic Zenith TX2 endografts were used to repair the thoracic and the thoracoabdominal aorta. A bifurcated Zenith AAA device was used to treat the aneurysm at the level of the infrarenal aorta and both iliac arteries. Despite covering the LSA and all intercostal and lumbar arteries, the patient developed only a temporary paresis of the left leg. Computed tomography showed complete exclusion of the aneurysm and normal flow to the supra-aortic and visceral arteries.

CONCLUSION

In selected cases, this hybrid approach using the ascending aorta for antegrade revascularization of cerebral and visceral arteries is feasible, with acceptable perioperative morbidity. However, its role for the treatment of complex thoracoabdominal aortic disease must be evaluated further.

Successful descending thoracic aortic aneurysm repair during a twin pregnancy: case report and literature review

A 28-year-old woman in the first trimester of a twin pregnancy presented with a symptomatic descending thoracic aortic aneurysm. We report our experience in managing a descending thoracic aortic aneurysm in this patient.

Optimization of Aortic Arch Replacement: Two-Stage Approach

BACKGROUND

Aneurysms of the aortic arch seldom occur alone. They usually involve the ascending aorta. Occasionally, the aneurysm also involves the descending thoracic or thoracoabdominal aorta. We advocate a staged approach for repair of these extensive aortic aneurysms, with the ascending and arch generally being repaired in the first stage and the descending thoracic or thoracoabdominal aorta being repaired in the second stage.

METHODS

Between February 1991 and December 2005, we repaired aneurysms of the ascending, arch, descending thoracic, and thoracoabdominal aorta in 2120 patients. Of these, 254 (12.0%) involved the ascending, arch, and descending aorta (extensive aortic aneurysm). A first-stage repair was done in 254 patients, and 115 returned for a second-stage repair for a total of 369 procedures performed.

RESULTS

First-stage 30-day mortality was 6.3% (16/254), with the glomerular filtration rate (GFR) exceeding 70 mL/min in 2.9% of patients and less than 70 mL/min in 10.5% (p < 0.03). Second-stage 30-day mortality was 9.6% (11/115), with GFR exceeding 70 mL/min in 4.9% and less than 70 mL/min in 9.8% (not significant). The incidence of postoperative stroke for the first stage was 2.0% (5/254), and the rate of neurologic deficit (paraplegia and paraparesis) was .9% (1/115) in the second stage. The mortality for the interval of 31 days to 6 weeks after the first-stage operation was 2.9% (7/238).

CONCLUSIONS

Aneurysms involving the transverse arch with extensive involvement of the ascending and descending thoracic or thoracoabdominal aorta can be effectively repaired using the two-stage technique with acceptable morbidity and mortality. GFR correlates to surgical outcome in the first-stage repair. After the first stage, prompt treatment of the remaining segment of aorta is crucial to success.

Long-Term Follow-Up After Thoracoabdominal Aortic Aneurysm Repair

BACKGROUND

Early mortality and morbidity after thoracoabdominal aortic aneurysm (TAAA) repair has been analyzed extensively; however, very few studies have examined the risk factors for late death.

METHODS

We analyzed 500 consecutive TAAA repairs performed at St. Antonius Hospital between 1981 and March 30, 2006. Survival and freedom from aortic reoperation were calculated using the Kaplan-Meier method, and the effects of preoperative, intraoperative, and postoperative risk factors were evaluated using Cox proportional hazard analysis. Survival was compared with a Dutch population matched for age, sex, and date of operation.

RESULTS

Patient survival with 95% confidence intervals (CI) was 83% (80% to 86%), 63% (58% to 67%), 34% (29% to 40%), 16% (9% to 20%), and 6% (2% to 11%) after 1, 5, 10, 15, and 20 years, respectively, compared with 100%, 99%, 85%, 36%, and 15% for the matched Dutch population. Hazard analysis showed an early phase of high hazard falling to low levels 9 months postoperatively and a late phase in which the hazard of death gradually increased. Incremental risk factors for late death were depressed left ventricular function (p < 0.001), increased age (p < 0.001), urgency (p = 0.007), postoperative dialysis (p < 0.001), and postoperative neurologic deficit (p = 0.016). Freedom from reoperation on the aorta with 95% CI was 98% (97% to 99%), 92% (89% to 94%), 86% (82% to 90%), 83% (78% to 87%), and 83% (78% to 87%) after 1, 5, 10, 15, and 20 years, respectively.

CONCLUSIONS

Survival remains suboptimal, especially in the early years after TAAA repair, compared with a matched population. Avoidance of postoperative problems such as dialysis and neurologic deficits and performing elective surgery on relative young patients with unimpaired ventricular function will increase the likelihood of late survival.

Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases

BACKGROUND

With the US Food and Drug Administration approval of the TAG thoracic device, more thoracic pathologies are being treated using endovascular techniques. Although endovascular abdominal and thoracic aortic repairs have some apparent similarities, there are substantive anatomic, pathologic, and technical differences that could impact perioperative outcomes. The purpose of this study is to identify these differences.

METHODS

During a 5-year period, 121 endovascular thoracic aortic repairs (TEVAR) and 450 abdominal aortic repairs (EVAR) were performed at a single institution. Preoperative, intraoperative, and early postoperative data were prospectively collected and retrospectively reviewed. Aggregate outcome measures were compared between the two cohorts, with statistical significance achieved at P < .05.

RESULTS

The mean age of patients undergoing EVAR was 72.8 +/- 8.3 compared with 68.3 +/- 13.9 for TEVAR (P = .02). More women underwent TEVAR (30.6% vs 11.1%, P < .001). Aneurysms undergoing TEVAR were larger than those for EVAR (62.0 mm vs 58.3 mm, P = .01). Intraoperatively, EVAR required 26.2 minutes of fluoroscopy compared with 22.1 minutes for TEVAR (P < .001). The amount of contrast used was higher in TEVAR (133.6 mL vs 93.6 mL, P < .001). The mean procedure times were 164 minutes for EVAR and 115 minutes for TEVAR (P < .001). Iliac conduits were required in 46 patients (10.2%) undergoing EVAR, and in 24 (19.8%) undergoing TEVAR (P = .007). The 30-day or in-hospital mortality was 2.0% for EVAR and 5.0% for TEVAR (P = NS). The median length of stay was longer for TEVAR (3 days vs 2 days, P =.034). There were 54 postoperative complications in 36 TEVAR patients (29.8%), including 13 neurologic (10.7%), 8 renal (6.6%), 7 pulmonary (5.8%), 6 ischemic (5.0), and 5 (4.1%) hemorrhagic events. Among the EVAR group, 136 (30.2%) patients had postoperative complications, which included 45 ischemic (10.0%), 34 wound (7.6%), 22 renal (4.9%), 12 cardiac (2.7%), 8 pulmonary (1.8%), 5 gastrointestinal (1.1%), and 4 neurologic (0.9%) events.

CONCLUSIONS

A relatively higher proportion of women underwent TEVAR than EVAR, and this was reflected in the greater need for iliac conduits to accommodate the larger delivery catheters of the thoracic devices. Intraoperative imaging techniques were also different, and TEVAR required higher contrast volumes despite shorter overall procedure times. The incidence of strokes and spinal cord ischemia was also higher during TEVAR. Despite apparent similarities of devices and techniques, EVAR and TEVAR are fundamentally different procedures with different perioperative outcomes.

Stent-graft versus open-surgical repair of the thoracic aorta: Mid-term results

OBJECTIVE

Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta.

METHODS

A review of patients undergoing SG procedures and open surgery of the thoracic aorta from January 1, 1996, to November 30, 2005, was performed from a prospectively compiled database. Study end points included perioperative complications, late survival, freedom from reinterventions, and graft-related complications. Multivariate methods were used to assess variables potentially associated with study end points; late outcomes were compared with actuarial methods.

RESULTS

In 105 patients (mean age, 70 years; 66 male [62.9%]) SG repairs were done for 68 degenerative aneurysms (64.7%), 12 penetrating ulcers (11.4%), 15 pseudoaneurysms (14.3%), 9 traumatic tears (8.6%), and 1 acute dissection (0.9%). Mean follow-up was 22 months (range, 0 to 101 months). Eighty-nine (84.8%) SG patients were asymptomatic at presentation and underwent elective repair, whereas 16 (15.2%) presented with acute conditions and underwent urgent repair. Perioperative mortality was 7.6% (8/105), and actuarial survival at 48 months was 54% +/- 7%. The perioperative mortality rate among SG patients treated for degenerative pathology was 10.4% (8/77). Seven (6.7%) of 105 patients experienced spinal cord ischemic complications, including 2 patients with transient paraparesis that resolved by the time of discharge. Reinterventions were performed in 10.5% of patients (11/105), with freedom from reintervention approaching 81% by 48 months. Over the same interval, 93 patients were treated with open-surgical repair for descending thoracic aneurysm (anastomosis cephalad to the celiac axis). Perioperative mortality in the open cohort was 15.1% (14/93; P = .09 vs SG repair), and the 48-month actuarial survival was 64% +/- 6%. The incidence of spinal cord ischemic complications was 8.6% (8/93), including 4 patients with transient paraparesis (P = .44 vs SG repair). Nine patients (9.7%) required surgical reintervention during the follow-up period, with 48-month freedom from reintervention approaching 79% (P = .73 vs SG repair).

CONCLUSIONS

Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications.

Outcomes of Medical Management of Acute Type B Aortic Dissection

BACKGROUND

Currently, the optimal treatment of acute type B aortic dissection remains controversial. The purpose of this study was to report early clinical outcomes of medical management for acute type B aortic dissection.

METHODS AND RESULTS

Between January 2001 and March 2005, 129 consecutive patients with the confirmed diagnosis of acute type B aortic dissection were studied. Mean age was 61 years (range, 29 to 94), with 33.3% (43/129) female. Acute type B aortic dissection protocol was instituted with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, malperfusion, and intractable pain. All patients were followed-up after discharge. Hospital mortality was 10.1% (13/129), 19% (4/21) when vascular intervention was required, and 8.3% (9/108) when medical management was maintained. Early intervention was required in 21 cases (16.2%), 19 (14.7%) open vascular/aortic cases and 2 cases (1.6%) of percutaneous aortic interventions. Morbidity included rupture (4.7%), stroke (4.7%), paraplegia (8.5%), bowel ischemia (7%), acute renal failure (21%), dialysis requirement (13%), and peripheral ischemia (4.7%). Late vascular-related procedures were performed in 5.2% (6/116) of cases. Univariate risk factors for early mortality were rupture (P<0.0001), need for laparotomy (P<0.008), acute renal failure (P<0.0001), need for dialysis (P<0.0001), and lower extremity ischemia (P<0.0004). The only independent risk factors for hospital mortality by multiple logistic regression was rupture (P<0.0009), and independent risk factors for midterm death were history of chronic obstructive pulmonary disease (P<0.002) and low glomerular filtration rate (<57 mL/min; P<0.0001).

CONCLUSIONS

Medical management for acute type B aortic dissection is associated acceptable outcomes. Outcomes of other management strategies, eg, endovascular stenting, for acute type B aortic dissection need to be compared with these results.

Adjuncts during surgery of the thoracoabdominal aorta and their impact on neurologic outcome: distal aortic perfusion and cerebrospinal fluid drainage

The adjunct (distal aortic perfusion, cerebrospinal fluid drainage, and moderate hypothermia) has been our mainstay in the prevention of paraplegia and paraparesis during repair of the descending thoracic and thoracoabdominal aorta.